Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Luke's Elmore Long Term Care during CMS and state inspections, most recent first.
Surveyors observed spoiled strawberries with visible mold stored in a refrigerator alongside fresh produce and snacks, and the Food Service Manager acknowledged they should have been discarded. During a meal tray line, a staff member repeatedly handled ready-to-eat foods such as dinner rolls and fresh fruit without changing gloves or performing hand hygiene after touching other surfaces, including a refrigerator door. The Food Service Manager stated she was not concerned about this practice, despite acknowledging it increases the risk of cross-contamination.
Surveyors observed a medication cart left unattended in a hallway with a laptop logged into the EMR system, displaying multiple resident records, and no staff present to monitor or secure the information. In an interview, the Interim DON confirmed that the facility’s expectation is that resident records remain secured to prevent unauthorized access, indicating that this situation did not meet established standards for protecting resident information.
A resident with leukemia and rheumatoid arthritis was allowed to self-administer cyclosporine eye drops without a documented assessment of their ability to safely do so. An RN placed a single-use vial of the eye drops at the bedside and instructed the resident to use them whenever desired and report back later. The Interim DNS reported that staff had observed the resident self-administering the drops appropriately, but confirmed that no formal self-administration of medication assessment had been completed or documented, as required.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident who used CPAP and had never required an invasive mechanical ventilator was incorrectly coded on the Quarterly MDS as receiving invasive mechanical ventilation. Another resident with documented bipolar disorder, depression, and anxiety and an Abbreviated Level 2 PASRR identifying severe mental illness was coded on the Admission MDS as not being considered by the state Level 2 PASRR process to have a serious mental illness or related condition. The MDS Coordinator acknowledged both errors and lack of awareness regarding the need to align PASRR findings with MDS coding.
A resident admitted with heart disease, bipolar disorder, depression, and anxiety did not have her mental health diagnoses or related interventions included in her comprehensive care plan. Record review showed that bipolar disorder, depression, and anxiety were missing from the care plan, and there were no directions for staff on how to address these mental health needs. In an interview, the Resident Service Advocate acknowledged that the mental health conditions were not included in the care plan and stated they were excluded in error.
A facility failed to ensure accurate MDS assessments for a resident with bipolar disorder and anxiety disorder. Despite having a PASARR level II indicating a serious mental illness, the MDS assessments incorrectly documented the absence of this status. The MDS Coordinator noted a discrepancy between the electronic health record system and the MDS wording, leading to the error.
A resident's medications were not administered as scheduled due to staff distraction. The ADON prepared the medications, but after the resident left to use the restroom, the medications were placed back in the cart and not given at the scheduled time, creating potential adverse effects.
Two residents in a LTC facility experienced significant medication errors. One resident received medications intended for another, including incorrect doses and timing, while another received an incorrect insulin dose. Both incidents were discovered promptly, and no adverse effects were documented. The facility's DON confirmed the errors and mentioned an ongoing Quality Improvement project.
Improper Food Storage and Unsanitary Handling of Ready-to-Eat Items
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage and handling practices based on observations and staff interviews. During a kitchen tour, a container of soft strawberries with fuzzy white substances was found in the front kitchen refrigerator where fresh produce and snacks were stored. The Food Service Manager stated that staff relied on visual inspection to determine spoilage and acknowledged that the strawberries should have been discarded, indicating that spoiled produce had not been removed from an area used for resident food items. During a tray line observation, a staff member preparing resident meal trays was seen handling ready-to-eat foods without maintaining proper hand hygiene or glove use. The staff member left the workstation to obtain sorbet, then returned and immediately picked up a dinner roll with the same gloved hand without performing hand hygiene or changing gloves. Later, the same staff member opened a refrigerator door with a gloved hand, retrieved a bowl of fresh fruit, and then handled another dinner roll with that same glove. The Food Service Manager stated she was not concerned about the staff member touching other surfaces while handling ready-to-eat food, though she acknowledged that touching additional surfaces increases the risk for cross-contamination.
Unattended Medication Cart with Open EMR Exposes Resident Records
Penalty
Summary
Surveyors identified a deficiency in safeguarding resident-identifiable information when a medication cart was observed unattended in the hallway in front of a resident room. The cart contained a laptop that was logged into the electronic medical record system, with the screen displaying access to multiple resident records. At the time of the observation, no staff member was present at the cart to monitor or secure the device or the information displayed. During an interview shortly after the observation, the Interim Director of Nursing stated that the facility’s expectation is that resident records are to remain secured to prevent unauthorized access, confirming that the observed practice did not align with facility expectations for protecting resident medical records.
Failure to Assess Resident’s Ability to Self-Administer Eye Drops
Penalty
Summary
The facility failed to ensure that a resident who was self-administering medication was properly assessed for the ability to do so. Resident #4, admitted with multiple diagnoses including leukemia and rheumatoid arthritis, was observed on 1/22/26 at 8:34 AM when RN #1 placed a single-use vial of cyclosporine eye drops on her bedside table and told her she could use them whenever she wanted and to inform him later. The Interim DNS later stated on 1/22/26 at 9:44 AM that staff had observed Resident #4 appropriately self-administering her eye drops; however, the facility had not performed or documented any formal self-administration of medication assessment for this resident. This failure was identified for 1 of 1 resident whose record was reviewed for self-administration of medications assessment and was noted in the report as placing Resident #4 at risk for adverse outcomes if she were to use the medication inappropriately.
Inaccurate MDS Coding for Respiratory Treatment and PASRR Mental Illness Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ conditions and services for two residents. One resident was admitted with multiple diagnoses including dementia, Parkinson’s disease, kidney failure, and obstructive sleep apnea. The resident used a CPAP machine for respiratory support and, according to the Interim DNS, had never required an invasive mechanical ventilator. However, the resident’s Quarterly MDS dated 11/1/25 documented “yes” at item F1 in Section O, indicating use of an invasive mechanical ventilator. The MDS Coordinator later stated that this item had been marked “yes” in error, confirming that the assessment did not accurately represent the resident’s actual respiratory treatment. Another resident was admitted with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. The resident’s record contained an Abbreviated Level 2 PASRR dated 12/10/25, which documented at item 33 that the individual had a current diagnosis of severe mental illness per PASRR criteria, listing bipolar disorder, depression, and anxiety. Despite this, the resident’s Admission MDS dated 12/17/25 documented “no” at item A1500, which asks whether the resident is currently considered by the state Level 2 PASRR process to have a serious mental illness and/or intellectual disability or related condition. The MDS Coordinator stated she was not aware that item 33 on the PASRR Level 2 form needed to be reflected on the MDS and acknowledged that the Admission MDS was not accurate for this resident.
Mental Health Diagnoses Omitted From Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident’s identified needs, specifically omitting mental health diagnoses and related interventions. One resident was admitted with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. Review of this resident’s comprehensive care plan showed that the bipolar disorder, depression, and anxiety diagnoses were not documented, and there were no interventions outlining how staff were to address or manage the resident’s mental health needs. In a staff interview, the Resident Service Advocate confirmed that these mental health conditions were not included in the resident’s comprehensive care plan and stated they were excluded in error. This failure placed the resident at risk for her mental health needs to go unmet because her mental health diagnoses were not included in her care plan.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for residents, specifically for one resident with a serious mental illness. This resident, diagnosed with bipolar disorder and anxiety disorder, had a PASARR level II completed, indicating a serious mental illness. However, the MDS assessments for this resident, conducted on multiple occasions, incorrectly documented that the resident did not have a PASARR level II. The MDS Coordinator acknowledged the discrepancy, noting that the electronic health record system and the MDS were worded differently, leading to the incorrect marking of the PASARR status on the MDS.
Medication Administration Lapse
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice, as observed during a survey. A medication cup containing multiple medications for a resident was found inside the medication cart, indicating that the medications were not administered as per the physician's order. The medications included Allegra, Metformin, acetaminophen, lactulose, and Vitamin D3, which were prescribed to be given at specific times. The resident, who had a history of stroke and dementia, was supposed to receive these medications at 8:00 am, but they were not administered due to the staff's distraction. The Assistant Director of Nursing (ADON) prepared the medications for the resident, but when attempting to administer them, the resident needed to use the restroom. Upon returning, the resident was not in their room, leading the ADON to place the medication cup back in the cart. The ADON admitted to being distracted and failing to administer the medications at the scheduled time. This oversight created the potential for adverse effects on the resident due to the delay in medication administration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were protected from significant medication errors, affecting two residents. One resident was administered eight medications intended for another resident during morning medication rounds. This included three medications not prescribed to him, three medications at incorrect doses, and two medications at incorrect times. The error was discovered immediately, and the resident's physician was notified. The resident was monitored for adverse effects, but none were documented. Another resident received an incorrect dose of long-acting insulin, receiving 10 units instead of the ordered 14 units. Upon discovering the error, the nurse notified the resident's physician, who recommended monitoring without additional dosing. No adverse effects were noted during the monitoring period. The facility's Director of Nursing confirmed these medication administration errors and mentioned an ongoing Quality Improvement project to address such errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mountain Home
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Terraces Of Boise, The | 36.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.